Tracking resource and policy impact in Malawi : Incorporating Malawi poverty reduction strategy paper indicators, millennium development goals & poverty monitoring across sectors

This report is prepared jointly by National Statistical Office in Malawi and Statistics Norway. The objective has been to establish a system for statistical information to follow the potential effects of resources related to poverty and/or allocated to social sectors and through all steps from available public service towards the final outcome and end goals. This has included overall national policies affecting resource allocation for social sectors; allocation and distribution of resources between and within sectors; access to and use of social service; outcome and achievements; poverty reduction and other end goals; and feed back to economic, human and social development. The information presented aims at allowing the reader to follow resource allocation from policy decisions towards human welfare and quality of life, and the feed back towards economic and social development. Data presented are selected to provide information for indicators of the Malawi Poverty Reduction Strategy Paper and the Millennium Development Goal indicators and resources which potentially might affect these indicators

Countdown to 2015 country case studies: what have we learned about processes and progress towards MDGs 4 and 5?

Background: Countdown to 2015 was a multi-institution consortium tracking progress towards Millennium Development Goals (MDGs) 4 and 5. Case studies to explore factors contributing to progress (or lack of progress) in reproductive, maternal, newborn and child health (RMNCH) were undertaken in: Afghanistan, Bangladesh, China, Ethiopia, Kenya, Malawi, Niger, Pakistan, Peru, and Tanzania. This paper aims to identify cross-cutting themes on how and why these countries achieved or did not achieve MDG progress. Methods: Applying a standard evaluation framework, analyses of impact, coverage and equity were undertaken, including a mixed methods analysis of how these were influenced by national context and coverage determinants (including health systems, policies and financing). Results: The majority (7/10) of case study countries met MDG-4 with over two-thirds reduction in child mortality, but none met MDG-5a for 75 % reduction in maternal mortality, although six countries achieved >75 % of this target. None achieved MDG-5b regarding reproductive health. Rates of reduction in neonatal mortality were half or less that for post-neonatal child mortality. Coverage increased most for interventions administered at lower levels of the health system (e.g., immunisation, insecticide treated nets), and these experienced substantial political and financial support. These interventions were associated with ~30–40 % of child lives saved in 2012 compared to 2000, in Ethiopia, Malawi, Peru and Tanzania. Intrapartum care for mothers and newborns -- which require higher-level health workers, more infrastructure, and increased community engagement -- showed variable increases in coverage, and persistent equity gaps. Countries have explored different approaches to address these problems, including shifting interventions to the community setting and tasks to lower-level health workers. Conclusions: These Countdown case studies underline the importance of consistent national investment and global attention for achieving improvements in RMNCH. Interventions with major global investments achieved higher levels of coverage, reduced equity gaps and improvements in associated health outcomes. Given many competing priorities for the Sustainable Development Goals era, it is essential to maintain attention to the unfinished RMNCH agenda, particularly health systems improvements for maternal and neonatal outcomes where progress has been slower, and to invest in data collection for monitoring progress and for rigorous analyses of how progress is achieved in different contexts. Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-3401-6) contains supplementary material, which is available to authorized users

Strengthening Community-Based Vital Events Reporting for Real-Time Monitoring of Under-Five Mortality: Lessons Learned from the Balaka and Salima Districts in Malawi.

BACKGROUND:Malawi ratified a compulsory birth and death registration system in 2009. Until it captures complete coverage of vital events, Malawi relies on other data sources to calculate mortality estimates. We tested a community-based method to estimate annual under-five mortality rates (U5MR) through the Real-Time Monitoring of Under-Five Mortality (RMM) project in Malawi. We implemented RMM in two phases, and conducted an independent evaluation of phase one after 21 months of implementation. We present results of the phase two validation that covers the full project time span, and compare the results to those of the phase one validation. METHODS AND FINDINGS:We assessed the completeness of the counts of births and deaths and the accuracy of disaggregated U5MR from the community-based method against a retrospective full pregnancy history for rolling twelve-month periods after the independent evaluation. We used full pregnancy histories collected through household interviews carried out between November 2013 and January 2014 as the validation data source. Health Surveillance Agents (HSAs) across the 160 catchment areas submitted routine reports on pregnancies, births, and deaths consistently. However, for the 15-month implementation period post-evaluation, average completeness of birth event reporting was 76%, whereas average completeness of death event reporting was 67% relative to that expected from a comparable pregnancy history. HSAs underestimated the U5MR by an average of 21% relative to that estimated from a comparable pregnancy history. CONCLUSIONS:On a medium scale, the community-based RMM method in Malawi produced substantial underestimates of annualized U5MR relative to those obtained from a full pregnancy history, despite the additional incentives and quality-control activities. We were not able to achieve an optimum level of incentive and support to make the system work while ensuring sustainability. Lessons learned from the implementation of RMM can inform programs supporting community-based interventions through HSAs in Malawi

Monitoring Child Mortality through Community Health Worker Reporting of Births and Deaths in Malawi: Validation against a Household Mortality Survey

<div><p>Background</p><p>The rate of decline in child mortality is too slow in most African countries to achieve the Millennium Development Goal of reducing under-five mortality by two-thirds between 1990 and 2015. Effective strategies to monitor child mortality are needed where accurate vital registration data are lacking to help governments assess and report on progress in child survival. We present results from a test of a mortality monitoring approach based on recording of births and deaths by specially trained community health workers (CHWs) in Malawi.</p><p>Methods and Findings</p><p>Government-employed community health workers in Malawi are responsible for maintaining a Village Health Register, in which they record births and deaths that occur in their catchment area. We expanded on this system to provide additional training, supervision and incentives. We tested the equivalence between child mortality rates obtained from data on births and deaths collected by 160 randomly-selected and trained CHWs over twenty months in two districts to those computed through a standard household mortality survey. CHW reports produced an under-five mortality rate that was 84% (95%CI: [0.71,1.00]) of the household survey mortality rate and statistically equivalent to it. However, CHW data consistently underestimated under-five mortality, with levels of under-estimation increasing over time. Under-five deaths were more likely to be missed than births. Neonatal and infant deaths were more likely to be missed than older deaths.</p><p>Conclusion</p><p>This first test of the accuracy and completeness of vital events data reported by CHWs in Malawi as a strategy for monitoring child mortality shows promising results but underestimated child mortality and was not stable over the four periods assessed. Given the Malawi government's commitment to strengthen its vital registration system, we are working with the Ministry of Health to implement a revised version of the approach that provides increased support to CHWs.</p></div

Number of HSAs who reported data by month from January 2010 to December 2011 by district (number of HSAs = 80 per district).

<p>Number of HSAs who reported data by month from January 2010 to December 2011 by district (number of HSAs  = 80 per district).</p

Ratio of under-five mortality rates.

<p>Ratio of under-five mortality rates, RMM data to midline and endline surveys, for annual periods from January 2010 through December 2013 (%).</p

Comparison of births and under-five deaths reported by HSAs to expected births and deaths based on validation survey.

<p>Comparison of births and under-five deaths reported by HSAs to expected births and deaths based on validation survey.</p

Infant mortality rates from HSA records and validation survey, the ratio of the two rates and corresponding 95% confidence intervals.

<p>Infant mortality rates from HSA records and validation survey, the ratio of the two rates and corresponding 95% confidence intervals.</p

RMM Timeline.

<p>Timeline of RMM implementation, validations, and meetings from January 2010 through December 2013.</p

Under-five mortality estimates.

<p>Under-five mortality rate estimates, RMM and midline and endline survey data, for annual periods from January 2010 through December 2013 (per 1,000).</p